American Journal of Infection Control 43 (2015) 400-1
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Group B Streptococcus: Compliance with the information in prenatal card records and knowledge of pregnant women Débora Silva de Mello RN, MSc a, *, Maria Alice Tsunechiro RN, MSc, PhD b, Caroline Ataíde Mendelski RN b, Sandra Abib Pierre MD c, Atalanta Ruiz Silva MD d, Maria Clara Padoveze RN, MSc, PhD a a
Department of Collective Health Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil Infant Mortality Committee of the Vila Mariana and Jabaquara Region, Prefecture Health Department, São Paulo, Brazil d Infection Prevention and Control Committee, Amparo Maternal, São Paulo, Brazil b c
Key Words: Streptococcus agalactiae Prenatal care Population surveillance
This study aimed to determine the rate of compliance on prenatal cards and the women’s knowledge and feelings regarding Group B Streptococcus (GBS) screening in a maternity ward in São Paulo City, Brazil. Structured interviews and a review of prenatal card records of 391 women were performed. The GBS screening was not recorded in more than half of prenatal cards (51.4%, n ¼ 201); 169 women reported no knowledge or not remembering the GBS screening. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Maternal colonization with Group B Streptococcus (GBS) is a risk factor for early-onset sepsis in newborns. Based on the recommendations from the Centers for Disease Control and Prevention,1 the culture-based screening is the standard for all pregnant women at 35-37 weeks gestation in the public health care system of the city of São Paulo, Brazil. The protocol indicates that results of screening should be recorded on prenatal cards as a follow-up strategy aiming at facilitating the information flow across the entire health careeassistance line. This measure aims at preventing early-onset disease by identifying women who should receive intrapartum antibiotic prophylaxis.2 Prenatal care is usually performed at primary health care units (PHUs), which are public health care facilities under municipal government. Alternatively, pregnant women may choose to be followed at a private health care facility. A prenatal card contains the main records from health care professional consultation and examinations performed during pregnancy. However, in our practice, we have empirically observed that not all prenatal cards reflect compliance with this recommendation.
* Address correspondence to Débora Silva de Mello, RN, MSc, Departamento de Enfermagem em Saúde Coletiva. Av. Dr Enéas de Carvalho Aguiar, 419. CEP: 05403e000. São Paulo-SP, Brazil. E-mail address: [email protected] (D.S. de Mello). Funding/Support: C.A.M received scholarship support from the Provost of Research of University of São Paulo, Brazil. Conflicts of interest: None to report.
This study aimed to determine the rate of compliance on prenatal cards regarding GBS status. We also investigated the women’s knowledge and feelings on the examination procedures and its results. METHODS We carried out a prospective, cross-sectional, descriptive, and inferential study using structured interviews and a review of prenatal card records from December 2010-February 2011. Participants were recruited in a nonprofit maternity ward in São Paulo, Brazil, which cares for women having their prenatal care from both public and private systems. Until the planned sample size of at least 384 individuals was achieved, any women who had their prenatal card on admission for labor and were at a gestational age of 36 weeks were asked to participate in the study. Those who had prenatal follow-up in cities other than São Paulo were excluded. The research was approved by the Research Ethics Committee of the School of Nursing at the University of São Paulo (protocol no. 978/2010). RESULTS A total of 391 were enrolled in the study, with ages ranging from 13-40 years (mean SD, 24.8 5.8 years). Mean number of years of education was 9.4 2.4 (range, 2-16 years), and approximately half
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.026
D.S. de Mello et al. / American Journal of Infection Control 43 (2015) 400-1
had a paid occupation (51.9%; n ¼ 203). Most women had a steady sexual partner (80.1%, n ¼ 313). Primigravid and primaparous women were frequent among the studied population (49.1%, n ¼ 192 and 52.7%, n ¼ 206, respectively). Prenatal care began at 17 weeks gestation for most women (67.3%, n ¼ 263), with a mean number SD of 8.1 2.6 prenatal consultation visits. In most cases, delivery occurred at 38 weeks gestation. Although most enrolled women (80.1%, n ¼ 313) received their prenatal care in a PHU, a few received their prenatal care in a different setting, such as a hospital outpatient clinic (6.9%, n ¼ 27) or a private physician’s office (4.1%, n ¼ 16). Information regarding prenatal care was not available in 35 cases (8.9%). Overall, the GBS screening information was not recorded in more than half of the prenatal cards (51.4%, n ¼ 201). However, most women (n ¼ 271, 69.3%) reported to be sure that the screening was performed. Only half of the women who received prenatal care at the PHU were found to have had their GBS screening results recorded (n ¼ 156, 49.8%). For those women with prenatal cards showing the results of GBS screening, positive results were found in 52 (27.4%). Nevertheless, only 149 cards (78.4%) recorded the date of specimen collection. Of these, 45 (30.2%) showed that testing was performed outside of the recommended period (ie, 35-37 weeks of pregnancy), and most of these were aberrant screenings performed prior to 35 weeks (22.8%, n ¼ 34); 11 cases (7.4%) were performed after 37 weeks. We did not find any association between positive GBS results and social, demographic, and obstetric characteristics. The main results on knowledge and feelings from interviews are shown in Table 1. Among the women who have not received the results before the labor, most alleged that the baby was born before the following scheduled prenatal appointment, therefore they were not aware of these results. These results were presented and discussed with the Regional Committee of Maternal and Infant Mortality to provide subsidies for strategies to improve the GBS monitoring process. DISCUSSION The results from our study confirmed our initial hypothesis that flaws in the prenatal card records occur, which could influence neonatal outcomes, and demonstrates the need for further exploration regarding the cause. A relevant issue was the timing of screening, which occurred primarily outside of the recommended period. The period between 35 and 37 weeks gestation is considered to have the best sensitivity and specificity for the detection of women that are prone to be colonized during labor.1,3,4 Even when the screening was carried out within the recommended period, in many cases the results were likely available at the PHUs only after labor. Therefore, health care professionals in all PHUs should focus their efforts on providing screening during the correct period. Furthermore, one important strategy to implement is a fast-track process that allows the information to arrive in a reasonable timeframe. Our study suggests that women may have insufficient knowledge regarding GBS screening. This may affect their feelings and reflects possible limitations in communication of some health care professionals, who may not be aware of their role in providing enough information on the procedure. Further evaluations of PHU conditions that may hinder the achievement of these objectives are necessary. To our knowledge, the Regional Committee of Maternal and Infant Mortality of this region has been working on this area. Despite the population of the present study being only from one maternity ward and despite not being able to generalize the results,
401
Table 1 Knowledge and feelings of mothers on GBS cultureebased screening, São Paulo, Brazil, 2011 Questions in the interview* Do you have any knowledge on the GBS screening? (N ¼ 391) Yes I do not remember What is the reason of the examination?y (N ¼ 391) To find a bacteria To find a bacteria and to protect the newborn To find a bacteria, to protect the newborn, and for treatment To protect the newborn To protect the newborn and for treatment To find a bacteria and for treatment Nothing/ I do not know/ I do not remember Others (unrelated reason) What was your main source of information? (N ¼ 391) Health care professional Friends Family Other pregnant women Television Others Never heard about before What was your feeling regarding the procedure? (n ¼ 271) Indifferent Ashamed/embarrassed Afraid Tranquil Anxious Other Did you receive the results before the labor? (n ¼ 271) Yes No I do not remember Did you receive information on the results? (n ¼ 271) Yes No I do not remember What was your feeling after receiving the results? (n ¼ 112) Indifferent Feeling well Relieved Happy Concerned Tranquil Anxious Other
n
%
222 169
56.7 43.2
42 71 22 26 11 14 169 36
10.7 18.2 5.6 6.6 2.8 3.6 43.3 9.2
291 13 25 5 1 3 53
74.4 3.3 6.4 1.3 0.2 0.8 13.6
185 20 8 4 1 53
68.3 7.3 3.0 1.5 0.4 19.5
202 68 1
74,5 25.1 0.4
112 155 4
41.3 57.2 1.5
22 21 20 13 10 9 1 16
19.6 18.7 17.8 11.6 8.9 8.0 0.8 14.2
GBS, Group B Streptococcus. *Questions were summarized to fit the table. y As alleged by mothers.
the results point out that the same flaws may occur in other regions and different PHUs. In conclusion, this study pointed out that the strategy of GBS screening should be periodically monitored to evaluate its conformity and efficacy, mainly in countries and regions with limited resources. References 1. Verani JR, McGee L, Schrag SJ, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal diseaseerevised guidelines from CDC, 2010. MMWR Recomm Rep 2010;59:1-36. 2. São Paulo (SP). Municipal Health. Ordinance 1149/2009-SMS.G of 03/07/2009. Establishment of standards for the prevention of neonatal infection streptococcal hemolytic group B. DO Cidade de São Paulo, page 18-19. [Portuguese]. 3. Schrag S, Gorwitz R, Fultz-Butts K, Achuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002; 51:1-22. 4. Money DM, Dobson S. The prevention of early-onset neonatal group B streptococcal disease. J Obstet Gynaecol Can 2004;26:826-40.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Group B Streptococcus: Compliance with the information in prenatal card records and knowledge of pregnant women Débora Silva de Mello RN, MSc a, *, Maria Alice Tsunechiro RN, MSc, PhD b, Caroline Ataíde Mendelski RN b, Sandra Abib Pierre MD c, Atalanta Ruiz Silva MD d, Maria Clara Padoveze RN, MSc, PhD a a
Department of Collective Health Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil Department of Maternal-Child and Psychiatric Nursing, School of Nursing, University of São Paulo, São Paulo, Brazil Infant Mortality Committee of the Vila Mariana and Jabaquara Region, Prefecture Health Department, São Paulo, Brazil d Infection Prevention and Control Committee, Amparo Maternal, São Paulo, Brazil b c
Key Words: Streptococcus agalactiae Prenatal care Population surveillance
This study aimed to determine the rate of compliance on prenatal cards and the women’s knowledge and feelings regarding Group B Streptococcus (GBS) screening in a maternity ward in São Paulo City, Brazil. Structured interviews and a review of prenatal card records of 391 women were performed. The GBS screening was not recorded in more than half of prenatal cards (51.4%, n ¼ 201); 169 women reported no knowledge or not remembering the GBS screening. Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Maternal colonization with Group B Streptococcus (GBS) is a risk factor for early-onset sepsis in newborns. Based on the recommendations from the Centers for Disease Control and Prevention,1 the culture-based screening is the standard for all pregnant women at 35-37 weeks gestation in the public health care system of the city of São Paulo, Brazil. The protocol indicates that results of screening should be recorded on prenatal cards as a follow-up strategy aiming at facilitating the information flow across the entire health careeassistance line. This measure aims at preventing early-onset disease by identifying women who should receive intrapartum antibiotic prophylaxis.2 Prenatal care is usually performed at primary health care units (PHUs), which are public health care facilities under municipal government. Alternatively, pregnant women may choose to be followed at a private health care facility. A prenatal card contains the main records from health care professional consultation and examinations performed during pregnancy. However, in our practice, we have empirically observed that not all prenatal cards reflect compliance with this recommendation.
* Address correspondence to Débora Silva de Mello, RN, MSc, Departamento de Enfermagem em Saúde Coletiva. Av. Dr Enéas de Carvalho Aguiar, 419. CEP: 05403e000. São Paulo-SP, Brazil. E-mail address: [email protected] (D.S. de Mello). Funding/Support: C.A.M received scholarship support from the Provost of Research of University of São Paulo, Brazil. Conflicts of interest: None to report.
This study aimed to determine the rate of compliance on prenatal cards regarding GBS status. We also investigated the women’s knowledge and feelings on the examination procedures and its results. METHODS We carried out a prospective, cross-sectional, descriptive, and inferential study using structured interviews and a review of prenatal card records from December 2010-February 2011. Participants were recruited in a nonprofit maternity ward in São Paulo, Brazil, which cares for women having their prenatal care from both public and private systems. Until the planned sample size of at least 384 individuals was achieved, any women who had their prenatal card on admission for labor and were at a gestational age of 36 weeks were asked to participate in the study. Those who had prenatal follow-up in cities other than São Paulo were excluded. The research was approved by the Research Ethics Committee of the School of Nursing at the University of São Paulo (protocol no. 978/2010). RESULTS A total of 391 were enrolled in the study, with ages ranging from 13-40 years (mean SD, 24.8 5.8 years). Mean number of years of education was 9.4 2.4 (range, 2-16 years), and approximately half
0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2014.12.026
D.S. de Mello et al. / American Journal of Infection Control 43 (2015) 400-1
had a paid occupation (51.9%; n ¼ 203). Most women had a steady sexual partner (80.1%, n ¼ 313). Primigravid and primaparous women were frequent among the studied population (49.1%, n ¼ 192 and 52.7%, n ¼ 206, respectively). Prenatal care began at 17 weeks gestation for most women (67.3%, n ¼ 263), with a mean number SD of 8.1 2.6 prenatal consultation visits. In most cases, delivery occurred at 38 weeks gestation. Although most enrolled women (80.1%, n ¼ 313) received their prenatal care in a PHU, a few received their prenatal care in a different setting, such as a hospital outpatient clinic (6.9%, n ¼ 27) or a private physician’s office (4.1%, n ¼ 16). Information regarding prenatal care was not available in 35 cases (8.9%). Overall, the GBS screening information was not recorded in more than half of the prenatal cards (51.4%, n ¼ 201). However, most women (n ¼ 271, 69.3%) reported to be sure that the screening was performed. Only half of the women who received prenatal care at the PHU were found to have had their GBS screening results recorded (n ¼ 156, 49.8%). For those women with prenatal cards showing the results of GBS screening, positive results were found in 52 (27.4%). Nevertheless, only 149 cards (78.4%) recorded the date of specimen collection. Of these, 45 (30.2%) showed that testing was performed outside of the recommended period (ie, 35-37 weeks of pregnancy), and most of these were aberrant screenings performed prior to 35 weeks (22.8%, n ¼ 34); 11 cases (7.4%) were performed after 37 weeks. We did not find any association between positive GBS results and social, demographic, and obstetric characteristics. The main results on knowledge and feelings from interviews are shown in Table 1. Among the women who have not received the results before the labor, most alleged that the baby was born before the following scheduled prenatal appointment, therefore they were not aware of these results. These results were presented and discussed with the Regional Committee of Maternal and Infant Mortality to provide subsidies for strategies to improve the GBS monitoring process. DISCUSSION The results from our study confirmed our initial hypothesis that flaws in the prenatal card records occur, which could influence neonatal outcomes, and demonstrates the need for further exploration regarding the cause. A relevant issue was the timing of screening, which occurred primarily outside of the recommended period. The period between 35 and 37 weeks gestation is considered to have the best sensitivity and specificity for the detection of women that are prone to be colonized during labor.1,3,4 Even when the screening was carried out within the recommended period, in many cases the results were likely available at the PHUs only after labor. Therefore, health care professionals in all PHUs should focus their efforts on providing screening during the correct period. Furthermore, one important strategy to implement is a fast-track process that allows the information to arrive in a reasonable timeframe. Our study suggests that women may have insufficient knowledge regarding GBS screening. This may affect their feelings and reflects possible limitations in communication of some health care professionals, who may not be aware of their role in providing enough information on the procedure. Further evaluations of PHU conditions that may hinder the achievement of these objectives are necessary. To our knowledge, the Regional Committee of Maternal and Infant Mortality of this region has been working on this area. Despite the population of the present study being only from one maternity ward and despite not being able to generalize the results,
401
Table 1 Knowledge and feelings of mothers on GBS cultureebased screening, São Paulo, Brazil, 2011 Questions in the interview* Do you have any knowledge on the GBS screening? (N ¼ 391) Yes I do not remember What is the reason of the examination?y (N ¼ 391) To find a bacteria To find a bacteria and to protect the newborn To find a bacteria, to protect the newborn, and for treatment To protect the newborn To protect the newborn and for treatment To find a bacteria and for treatment Nothing/ I do not know/ I do not remember Others (unrelated reason) What was your main source of information? (N ¼ 391) Health care professional Friends Family Other pregnant women Television Others Never heard about before What was your feeling regarding the procedure? (n ¼ 271) Indifferent Ashamed/embarrassed Afraid Tranquil Anxious Other Did you receive the results before the labor? (n ¼ 271) Yes No I do not remember Did you receive information on the results? (n ¼ 271) Yes No I do not remember What was your feeling after receiving the results? (n ¼ 112) Indifferent Feeling well Relieved Happy Concerned Tranquil Anxious Other
n
%
222 169
56.7 43.2
42 71 22 26 11 14 169 36
10.7 18.2 5.6 6.6 2.8 3.6 43.3 9.2
291 13 25 5 1 3 53
74.4 3.3 6.4 1.3 0.2 0.8 13.6
185 20 8 4 1 53
68.3 7.3 3.0 1.5 0.4 19.5
202 68 1
74,5 25.1 0.4
112 155 4
41.3 57.2 1.5
22 21 20 13 10 9 1 16
19.6 18.7 17.8 11.6 8.9 8.0 0.8 14.2
GBS, Group B Streptococcus. *Questions were summarized to fit the table. y As alleged by mothers.
the results point out that the same flaws may occur in other regions and different PHUs. In conclusion, this study pointed out that the strategy of GBS screening should be periodically monitored to evaluate its conformity and efficacy, mainly in countries and regions with limited resources. References 1. Verani JR, McGee L, Schrag SJ, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC). Prevention of perinatal group B streptococcal diseaseerevised guidelines from CDC, 2010. MMWR Recomm Rep 2010;59:1-36. 2. São Paulo (SP). Municipal Health. Ordinance 1149/2009-SMS.G of 03/07/2009. Establishment of standards for the prevention of neonatal infection streptococcal hemolytic group B. DO Cidade de São Paulo, page 18-19. [Portuguese]. 3. Schrag S, Gorwitz R, Fultz-Butts K, Achuchat A. Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR Recomm Rep 2002; 51:1-22. 4. Money DM, Dobson S. The prevention of early-onset neonatal group B streptococcal disease. J Obstet Gynaecol Can 2004;26:826-40.
